Rigid Endoscopic Evaluation of Conventional Adenoidectomy

7/29/2019 Rigid Endoscopic Evaluation of Conventional Adenoidectomy

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Rigid endoscopic evaluation of conventional

curettage adenoidectomy

D REGMI, N N MATHUR, M BHATTARAI

Department of Otolaryngology and Head and Neck Surgery, B P Koirala Institute of Health Sciences, Dharan, Nepal

AbstractObjectives: To evaluate the results of conventional adenoidectomy, using rigid endoscopy of the nasopharynx, and

to establish the role of such evaluation in facilitating complete adenoid removal via the curettage technique.

Design: Descriptive rigid endoscopic evaluation of the nasopharynx before and after adenoid curettage, and

following subsequent endoscopy-assisted adenoidectomy.

Setting: Tertiary referral centre.

Patients: Forty-one consecutive children with symptomatic adenoid hypertrophy scheduled to undergo

adenoidectomy.

Results: Rigid endoscopic evaluation indicated that conventional curettage, used alone, failed to completely

remove adenoid tissue from the superomedial choanae and anterior vault in all cases; incomplete removal was

also seen in other parts of the choanae (in 67.2 per cent of patients), the eustachian tube opening (63 per cent),

the nasopharyngeal roof (61.78 per cent) and the fossa of Rosenmuller (61 per cent). Subsequent rigid

endoscopy-assisted adenoidectomy successfully removed the residual adenoid tissue from all nasopharyngeal

sites, except the eustachian tube opening in two cases.

Conclusion: Conventional curettage adenoidectomy misses a substantial amount of adenoid tissue. Rigid

endoscopy-assisted adenoidectomy improves this result by enabling localisation of any residual adenoid tissue.

Key words: Adenoidectomy; Endoscopy; Otorhinolaryngologic Surgical Procedures

IntroductionAdenoidectomy is a commonly performed procedure inthe field of otolaryngology. It has traditionally beenconducted using the curettage method. This is a rela-tively blind technique which risks nasopharyngealinjury and incomplete adenoid removal; indeed, it has

been found to completely remove adenoid vegetationsin less than 30 per cent of cases.1

In 1992, Beckeret al. reported the use of endoscopy-assisted adenoidectomy.2 This technique uses a 0, 30,70 and 120 rigid nasal endoscope of 2.7 or 4 mmdiameter. It has the advantages of improved visualisa-tion and magnification, rigidity, superior haemostasis,reduction of unnecessary trauma, complete removalof adenoid tissue, and improved safety. Endoscopy-assisted adenoidectomy is generally perceived to bemore effective in clearing adenoid tissue, comparedwith the conventional curettage method, but this hasnot been objectively assessed.

Therefore, we undertook a descriptive, cross-sectional study evaluating the nasopharynx of 41consecutive paediatric adenoidectomy cases, using a

0, 30 and 70, rigid, 4 mm endoscope. The study

aimed (1) to evaluate the role of such endoscopy inassessing the adenoids before and after traditional cur-ettage adenoidectomy; (2) to assess the effectiveness ofcurettage adenoidectomy performed alone; and (3) toevaluate the possible role of such endoscopy in improv-ing the results of curettage adenoidectomy.

Materials and methodsWe included in the study 41 paediatric patients under-going adenoidectomy with or without other surgical

procedures (e.g. tonsillectomy or ventilation tube inser-tion), whose parents were willing to give informedconsent. We excluded patients with contraindicationsfor adenoidectomy, and those in whom the rigid naso-

pharyngeal endoscope could not be navigated up to thenasopharynx.

Ethical approval was obtained from our institutionsethical committee.

All patients underwent clinical history-taking, andwere assessed pre-operatively using relevant, noninva-sive investigations such as pure tone audiometry, impe-dance audiometry and X-ray (using a soft tissue, lateral

neck view with open mouth and neck extension).

Accepted for publication 2 June 2010 First published online 18 October 2010

The Journal of Laryngology & Otology (2011), 125, 5358. MAIN ARTICLE JLO (1984) Limited, 2010

doi:10.1017/S0022215110002100


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The nasal cavity was decongested with cottonsoaked in 0.05 per cent oxymetazoline.

The nasopharynx was inspected via the nasal cavityusing a 0, 30 and 70 rigid endoscope (Karl Storz,Tuttlingen, Germany) to assess the extent of adenoidtissue (this was the first endoscopy). The operating

surgeon was kept unaware of the findings.Surgery was performed under general anaesthesia

with orotracheal intubation, with the patient placed inRoses position. A BoyleDavis mouth gag of appro-

priate size was inserted. A small French rubber catheterwas inserted through the nostril and brought outthrough the mouth, and the ends were clinched for

palatal retraction.3 The operating surgeon assessed thesize and extent of the adenoid with the index fingerof the dominant hand. The adenoids were removed

by conventional curettage. Small tags of lymphoidtissue retained after curettage were removed with

punch forceps. Pressure haemostasis was achieved bypacking the area with sterile cotton gauze packssoaked in adrenaline (1:100 000), for three minutesunless contraindicated. If adrenaline was contraindi-cated, sterile gauze packs soaked with saline onlywere used.

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Thereafter, the patients nasal cavity and nasophar-ynx were again examined endoscopically, by thesame endoscopist as previously, to determine the com-

pleteness of adenoid tissue removal at different sites(this was the second endoscopy). If remnant adenoidtissue was seen, it was removed under endoscopiccontrol, and the final result again assessed endoscopi-cally (this was the third endoscopy).

Following curettage and endoscopy-assisted adenoi-dectomy, the volume of adenoid tissue removed wasmeasured using the displacement method (utilising a25 ml measuring cylinder).

ResultsPatients mean age standard deviation (SD) was8.83 2.77 years; most were aged seven to 12 years.The male to female ratio was 1.56:1. The mostcommon symptom was snoring (97.6 per cent), fol-lowed by nasal obstruction. Mouth-breathing was

seen in 85.5 per cent cases, and a sore throat in 80.5per cent (Table I).

All the patients had enlarged adenoids on X-ray (softtissue, lateral neck view).

The most common surgical procedure conductedwas adenotonsillectomy (n= 32), followed by adeno-

tonsillectomy with ventilation tube insertion (n= 6).Isolated adenoidectomy was performed in only onecase.

In seven cases, both choanae were completelyblocked by adenoid tissue, preventing passage of the4 mm rigid endoscope. In the remaining cases (n=

34), the nasopharynx could be easily accessed with a0, 30 and 70, 4 mm, rigid endoscope, and theadenoid tissue extent at various nasopharyngeal sitescould be studied satisfactorily.

Before curettage, adenoid tissue was found to bepresent in all cases in the nasopharyngeal roof and

superomedial choanae. Adenoid tissue was alsopresent in the anterior vault (in 91.6 per cent ofpatients), other parts of the choanae (84.15 per cent),the fossa of Rosenmuller (77.95 per cent) and the eusta-chian tube opening (76.45 per cent).

The second endoscopy could be easily performed inall cases. Excellent haemostasis was achieved in all

patients. In all cases, the curettage technique failed tocompletely remove adenoid tissue from the superome-dial choanae and the anterior vault. Other sites ofincomplete removal were (in descending order of fre-quency) other parts of the choanae (in 67.2 per centof patients), the eustachian tube opening (63 percent), the nasopharyngeal roof (61.78 per cent) andthe fossa of Rosenmuller (61 per cent) (Figure 1).The curettage method was most successful in removing

adenoid tissue from the nasopharyngeal roof; even so,38.2 per cent of patients had incomplete removal at thissite. Thus, further, endoscopy-guided clearance wasnecessary in all cases to ensure complete removal ofadenoid tissue. Data on the success of curettage adenoi-dectomy are presented in Table II.

Endoscopy-assisted adenoidectomy successfullyremoved the residual adenoid tissue from all nasophar-yngeal sites, except for the eustachian tube opening in

two cases (Figure 2). Thus, the success rate for com-plete adenoid remnant removal from the eustachiantube opening, under endoscopic guidance, was 89.4

per cent. For all other nasopharyngeal sites, a 100 percent success rate was achieved. Data on the successof endoscopy-assisted adenoidectomy are presentedin Table III.

The mean volume SD of adenoid tissue removedusing conventional curettage was 1.74 0.77 ml(range 0.503). In addition, endoscopy-assisted ade-noidectomy removed a mean volume SD of 0.91

0.34 ml (range 0.52). Thus, if endoscopy-assisted

adenoidectomy had not been performed, 34.3 percent of the total adenoid tissue volume would havebeen retained (this equates to 52.3 per cent of theadenoid tissue volume removed by curettage).

TABLE I

PATIENTS CLINICAL FEATURES

Clinical feature Patients

% n

Snoring 97.1 40Nasal obstruction 95.1 39Mouth-breathing 85.6 35Sore throat 80.5 33Sleep apnoea 29.3 12Ear ache 24.4 10Hearing loss 22 9

Nasal discharge 19.5 8Ear discharge 9.8 4Voice change 4.9 2Epistaxis 0 0

D REGMI, N N MATHUR, M BHATTARAI54


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The mean time SD required to perform the first,pre-operative endoscopy was 3.56 1.58 minutes(range 110), while that for the second, post-curettageendoscopy was 8.82 2.15 minutes (range 212).

Intra-operative complications were noted in twopatients, in the form of transient tachycardia while

packing with adrenaline-soaked gauze, immediatelyafter curettage adenoidectomy. This resolved uponremoval of the pack.

One patient developed a reactionary haemorrhagefrom the tonsillar bed six hours post-operatively; this

was managed successfully with bipolar cautery undergeneral anaesthesia.

The patients mean SD hospital stay was 3.76

0.487 days (range 35).

DiscussionThe objective of adenoidectomy is to remove thehypertrophic adenoid tissue that causes nasal airwayobstruction and pathological restriction of nasalairflow. Dissatisfaction with the safety and adequacyof clearance of conventional curettage adenoidectomyhas led to the development of alternative techniques,made possible by developments in fibre-optics andendoscopic instrumentation.57

The main disadvantage of curettage is that it is a rela-tively blind technique that may lacerate the choanaeand torus tubarius and graze the nasopharyngealmucosa; it may also merely skim the adenoid bulk,leaving behind obstructing tissue particularly at theeustachian tube openings and intranasal protrusions

and high in the nasopharynx.8

A popular alternativeto conventional curettage is endoscopy-assisted ade-noidectomy the second method employed in ourstudy.

Our study was designed to assess the success of con-ventional curettage adenoidectomy versus endoscopy-assisted adenoidectomy in removing adenoid tissuefrom different nasopharyngeal sites. We also aimedto assess the possible role of rigid endoscopic evalu-ation in improving the success of conventional curet-tage adenoidectomy.

The first, pre-operative endoscopy could not be con-

ducted in two patients due to bilateral inferior turbinatehypertrophy; these patients were thus excluded fromthe study. In the remaining cases (n= 41), theadenoid tissue was easily assessable prior to curettage,

FIG. 1

Site of residual adenoid tissue (AT) following conventional curettage. L = left; R= right; Cho= other parts of choana; ETO = eustachian tubeopening; FOR= fossa of Rosenmuller; SMC= superomedial choana; AV= anterior vault

TABLE II

PATIENT RESULTS FOR CURETTAGE ADENOIDECTOMY

AT site N1 N2 AT

present atEnd-1 (n)

AT

present atEnd-2 (n)

Complete

AT removal(%)

No Yes

L Cho 34 34 27 9 18 33.3R Cho 34 34 28 9 19 32.1L ETO 34 34 22 3 19 13.6R ETO 34 34 27 5 22 18.5L FOR 34 34 25 6 19 24R FOR 34 34 28 7 21 25

NP roof 34 34 34 13 21 38.2L & R SMC 24 24 24 0 24 0L & R AV 24 24 22 0 22 0

AT= adenoid tissue; N1= first endoscopy; N2= second endo-scopy; End-1=pre-operative endoscopy; End-2=post-curettage

endoscopy; L= left; R= right; Cho= other parts of choanae;ETO= eustachian tube opening; FOR= fossa of Rosenmuller;

NP= nasopharyngeal; SMC= superomedial choanae; AV=anterior vault

ENDOSCOPIC EVALUATION OF CURETTAGE ADENOIDECTOMY 55


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using a 0, 30 and 70, 4 mm, Hopkins rod rigidendoscope. The anterior vault and the superomedial

portion of the choanae were assessed with a 70Hopkins rod rigid endoscope and a posterior rhino-scopy mirror.

Pre-operatively, adenoid tissue was invariably foundat the nasopharyngeal roof, followed by the fossa ofRosenmuller (on the left in 73.5 per cent of patientsand on the right in 82.4 per cent) and the eustachiantube opening (64.7 per cent on the left and 79.4 percent on the right). We searched the literature butcould not locate any similar studies performed toassess the nasopharyngeal extent of adenoid tissue,

prior to performing curettage. In our study, the

adenoid tissue observed in the eustachian tube open-ings and nasopharyngeal vault correlated well withour patients symptoms of ear ache and snoring,respectively. We expect that the anatomical extent ofadenoid hypertrophy would affect its clinicalsymptomatology.

Following curettage adenoidectomy, we used cottongauze packs soaked in 1:100 000 adrenaline to pack the

nasopharynx for three minutes, to achieve haemostasis.Adrenaline packs were not contraindicated in any ofour cases. Patients were closely monitored for adrena-line side effects. We encountered transient tachycardiain two cases, which settled after removing the naso-

pharyngeal pack.Excellent peri-operative haemostasis was achieved

in all patients. We did not encounter any immediatepost-operative haemorrhage; this is consistent withthe results of Teppo et al.9 However, one patient (2.4

per cent) developed a reactionary haemorrhage fromthe right tonsillar bed six hours post-operatively; this

was managed successfully with bipolar cautery undergeneral anaesthesia. A prospective study has shownthat the incidence of reactionary haemorrhage is 28

per cent.10 Return to theatre for haemostasis wasrequired in 0.5% and 2%.1113 Thus, our complicationrate was within acceptable limits.

In the present study, a second nasopharyngealendoscopy was conducted following curettage adenoi-dectomy, and we noted that the extent of superomedialchoanae and anterior vault adenoid tissue wasunchanged from its pre-operative state (as viewed at

the first endoscopy). Other sites harbouring retained

adenoid tissue included (in descending order offrequency) other parts of the choanae (in 67.2 percent of patients), the eustachian tube opening(63 per cent), the nasopharyngeal roof (61.78 per

FIG. 2

Site of residual adenoid tissue (AT) following endoscopy-assisted adenoidectomy. L= left; R= right; Cho= other parts of choana;ETO= eustachian tube opening; FOR= fossa of Rosenmuller; SMC= superomedial choana; AV= anterior vault

TABLE III

PATIENT RESULTS FOR ENDOSCOPY-ASSISTEDADENOIDECTOMY

AT site N1 N2 AT

present atEnd-2 (n)

AT

present atEnd-3 (n)

Complete

AT removal(%)

Yes No

L Cho 34 34 18 18 0 100R Cho 34 34 19 19 0 100L ETO 34 34 19 17 2 89.4R ETO 34 34 22 22 0 100L FOR 34 34 19 19 0 100R FOR 34 34 21 21 0 100

NP roof 34 34 21 21 0 100L & R SMC 24 24 24 24 0 100L & R AV 24 24 22 22 0 100

AT= adenoid tissue; N1= first endoscopy; N2= second endo-scopy; End-2=post-curettage endoscopy; End-3=post endo-

scopy-assisted adenoidectomy endoscopy; Cho= other parts ofchoanae; ETO= eustachian tube opening; FOR= fossa ofRosenmuller; NP= nasopharyngeal; SMC= superomedialchoanae; AV= anterior vault



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cent) and the fossa of Rosenmuller (61 per cent). Thus,conventional curettage had not cleared the adenoid tissuecompletely in even a single case. These observationswould have not been possible had we not conducted asecond endoscopy after the curettage procedure. Hence,the second objective of our study was fulfilled.

Although we assessed all cases with a 70 rigidendoscope and a posterior mirror, we found the super-omedial choanae and anterior vault could only be eval-uated with a 0 and 30 endoscope, with regards to theextent of adenoid tissue. In addition, these two areaswere the most inaccessible sites for conventional curet-tage removal of adenoid tissue.

In the present study, conventional curettage adenoi-dectomy successfully removed adenoid tissue fromother parts of the choanae, the eustachian tubeopening and the fossa of Rosenmuller areas in 33, 16and 24.5 per cent of patients, respectively. By compari-

son, Bross-Soriano et al. studied 150 patients with anabsolute indication for adenoidectomy, in order toevaluate the efficacy of conventional adenoidectomy,using intra-operative endoscopic inspection of thenasopharynx, and to evaluate the need for endoscopy-guided revision surgery.

1They found residual

adenoid tissue in 107 cases, 45.3 per cent of whichinvolved the pharyngeal part of the eustachian tubes.Our study findings indicate a higher prevalence ofresidual adenoid tissue across a greater range of naso-

pharyngeal sites, following curettage adenoidectomy.Although not used in the present study, we believe

that adenoid tissue in the superomedial choanae andanterior vault can also be effectively dealt with usinga microdebrider or suction diathermy.

In the present study, endoscopy-assisted clearanceachieved complete adenoid removal in all but twocases. In these two patients, a small tag of adenoidtissue could not be removed from the eustachian tubeopening; this would have required very tightlycurved, small Blakesley or Takahashi forceps, whichwere unavailable.

Huang et al. treated 15 patients with symptomaticadenoid hypertrophy, using combined conventionaland endoscopic adenoidectomy (any residual adenoid

tissue was completely removed during an endoscopicrevision procedure).6 They concluded that (1) this

procedure could completely remove large amounts ofadenoid tissue without prolonging the operativetime, and (2) the endoscope provided a clear, directview that enabled the surgeon to remove adenoidtissue accurately, to evaluate and stop bleeding effec-tively, and to avoid unnecessary trauma. Thus, theseauthors believed that a combined approach employing

both conventional and endoscopic adenoidectomywas an effective and safe method for managingenlarged adenoids.

Kulak conducted a similar study of 125 adenoidect-omy cases, in which complete removal of adenoidtissue was achieved using an endoscopy-assistedmethod.14

In the present study, the first, pre-operative endo-scopy took 3.56 minutes on average. Curettage adenoi-dectomy took an average of 9.2 minutes, while thesecond, post-curettage endoscopy took an average of8.82 minutes. In comparison, in Cannon and col-leagues series of 130 endoscopy-assisted adenoidect-

omy cases, revision endoscopy was performed toclear residual adenoid tissue following curettage andtook less than 5 minutes.15

In the present study, the mean volume SD ofadenoid tissue removed via conventional curettagewas 1.74 0.77 ml (range 0.503), while thatremoved via endoscopy-assisted adenoidectomy was0.91 0.34 ml (range 0.52). Thus, failure to under-take endoscopy-assisted adenoidectomy would haveresulted in retention of 34.3 per cent of the total pre-operative adenoid tissue volume (equating to 52.3 percent of the adenoid volume removed by curettage).

The use of an endoscope during

adenoidectomy gives the surgeon a clear,

direct view, facilitating precise and complete

adenoid tissue removal, effective haemostasis,

and avoidance of unnecessary trauma

Endoscopy-assisted adenoidectomy allows

better adenoid tissue clearance, compared

with conventional curettage adenoidectomy,

by enabling localisation of residual adenoid

tissue especially in the superomedial choanae

and anterior vault

Conventional curettage adenoidectomy may

achieve the desired clinical results in patients

with adenoid hypertrophy; however,

endoscopic evaluation indicates that it fails to

completely remove adenoid tissue

All our patients were discharged on the third post-oper-ative day, giving a mean hospital stay SD of 3.76

0.487 days (range 35).The slightly older age of our patient group could

be attributed to parents waiting longer before

seeking health care for their child, due to differingattitudes to health care compared with other parts ofthe world.

ConclusionThe use of an endoscope gives surgeons a clear, directview of the nasopharynx, enabling them to removeadenoid tissue precisely and completely, to control

bleeding effectively, and to avoid unnecessary trauma.Endoscopy-assisted adenoidectomy improves the

results of conventional curettage adenoidectomy byenabling accurate localisation of residual adenoid

tissue, especially in the superomedial choanae andanterior vault areas.Conventional curettage adenoidectomy may achieve

the desired result in patients with adenoid hypertrophy;

ENDOSCOPIC EVALUATION OF CURETTAGE ADENOIDECTOMY 57


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however, endoscopic evaluation reveals that it fails toachieve complete adenoid removal and hence is lesssatisfactory than endoscopy-assisted adenoidectomy.Further research is needed to establish whether anato-mically complete adenoid removal leads to real clinical

benefit for patients.

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dren beyond sinus surgery. Otolaryngol Clin North Am 1996;29:10514

6 Huang HM, Chao MC, Chen YL, Hsiao HR. A combinedmethod of conventional and endoscopic adenoidectomy.

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the microdebrider. Ear Nose Throat J 1997;76:7248 Koltai PJ, Kalathia AS, Stanislaw P, Heras HA. Power-assisted

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9 Paradise JL. Tonsillectomy and adenoidectomy. In: BluestoneCD, Stool SF, Alper CM, Arjmand EM, Casselbrant ML,Dohar JE, Yellon RF, eds. Pediatric Otolaryngology, 4th edn.Philadelphia: Saunders, 2002

10 Drake-Lee A, Stokes M. A prospective study of length of stay of150 children following tonsillectomy and/or adenoidectomy.Clin Otolaryngol 1998;23:4915

11 Guida R, Muttucci K. Tonsillectomy and adenoidectomy: an in-

patient or out-patient procedure? Laryngoscope 1990;100:4913

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Address for correspondence:Dr N N Mathur,Professor,Department of ENT and Head Neck Surgery,

Vardhman Mahavir Medical College and Safdarjung Hospital,New Delhi 110029,India

E-mail: [email protected]

Dr N N Mathur takes responsibility for the integrity ofthe content of the paperCompeting interests: None declared


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Rigid Endoscopic Evaluation of Conventional Adenoidectomy